RESUMO
BACKGROUND: Direct oral anticoagulants (DOACs) provide patients with attractive options for anticoagulation in atrial fibrillation (AF). However, dosing these agents in the elderly can be challenging due to factors such as drug interactions, reduced renal function, and less frequent monitoring. This study addressed this challenge by reviewing the dosing of three commonly used DOACs (i.e. apixaban, dabigatran, and rivaroxaban) in elderly patients managed at a pharmacist-run anticoagulation clinic. METHODS: This was a single-center, retrospective cohort study. A total of 98 cases of DOAC therapy in patients with AF aged 75 years or older receiving care at a large urban healthcare center were identified via chart review. Dosing of each DOAC was assessed at therapy initiation and throughout treatment whenever a serum creatinine was reported, using the Cockcroft-Gault equation to estimate creatinine clearance (CrCl). Dose excursions (defined as instances where patients were exposed to non-Food and Drug Administration (FDA)-approved doses) were documented in each case. Rationales for dose excursions were determined by study investigators via review of progress notes and categorized using clinical judgement. RESULTS: Upon therapy initiation apixaban was dosed in accordance with FDA recommendations in 92.9% of patient cases, dabigatran in 91.2% of cases, and rivaroxaban in 86.1% of cases (p = 0.70). FDA-recommended dosing was maintained throughout treatment at the highest rates with dabigatran (88.2% versus 78.6% with apixaban and 58.3% with rivaroxaban; p = 0.01, p = 0.005 for dabigatran versus rivaroxaban). The most common rationales for dose excursion were fluctuation in estimated CrCl near the dosing cutoff, and recommendations from nonpharmacist providers co-managing the patient. CONCLUSIONS: Prescribing and maintaining FDA-recommended doses of DOAC agents in the elderly is more challenging than initially perceived. Fluctuations in renal function, comorbidities, and concomitant antiplatelet use may necessitate more individualized dosing strategies with these agents.
RESUMO
Mycobacteriophage Cabrinians is a newly isolated phage capable of infecting both Mycobacterium phlei and Mycobacterium smegmatis and was recovered from a soil sample in New York City, NY. Cabrinians has a genome length of 56,669 bp, encodes 101 predicted proteins, and is a member of mycobacteriophages in cluster F.
RESUMO
BACKGROUND: Older diabetic patients are at increased risk for skin infections, often with methicillin-resistant Staphylococcus aureus (MRSA). Linezolid offers oral therapy with MRSA coverage. We present a case of linezolid-associated hypoglycemia in a 64-year-old diabetic patient with presumed MRSA cellulitis. CASE SUMMARY: A 64-year-old man with diabetes was treated for cellulitis. Linezolid was started when amoxicillin/clavulanate failed. Within 7 days, he developed frequent diaphoresis and tremulousness, with glucoses of 30 to 60 mg/dL. Hypoglycemia worsened despite decreasing insulin use, discontinuing glyburide, and increasing caloric intake. The day of admission, he awoke with a glucose level of 30 mg/dL. He took no medications, ate a large breakfast, and presented to clinic. He was symptomatic with a glucose level of 35 mg/dL. Hypoglycemia persisted despite IV dextrose. Linezolid was discontinued immediately in favor of vancomycin. Dextrose was weaned and his diabetes medications were resumed without further hypoglycemia. CONCLUSIONS: Linezolid has monoamine oxidase (MAO) inhibitory properties, and MAO inhibitors have been reported to contribute to hypoglycemia. The use of linezolid in older diabetic patients, especially those patients already taking agents with the potential to cause hypoglycemia, represents an area of concern. Increased comorbidities and polypharmacy in geriatric patients adds to this concern.